[BCalvert]

#34234

Thank you for taking a look at this Dr. I had a successful 6mm herniation removal with an l4/l5 mirodiscectomy on 2/25/2020. All was good and I was making progress. At that time the MRI showed I also had 2mm bulges at l3/l4 and l5/s1.
A little over a year later. March or 2021 I started to have flare ups and pain again. First it was right side with pain in buttocks and down leg. Similiar to what I have felt in past. It comes and goes with no rhyme or reason it seams. I also have down left side as well but not consistently. This in in buttocks, but also down front of hip, thigh and to the knee. Also in groin slightly. I was given a second MRI for comparison with and without contrast. As well as xrays and this is what it said below. I am just comletely disheartened as to what to do. I assume I am going to just need to get used to life with pain. I see the Neurosurgeon in a 10 days to discuss the below findings. I have not been able to push myself with home PT and stengthening as I am/was afraid of making it worse. But it might be I got that all wrong. I am a healthy 5’7′ and 160 pound and up until this was very active in gym etc. Is there any hope for me here and what would you recommend as course of action? Epidural Injections?

I should add my pain levels are 3 on average with occational 5 at its worst right now. On days its a 1 or 2 I feel the weight of the world lifted off me. I have not taken a dose pak yet and have never been on any neurontins. I manage it fairly well with Ibuprofen and Tylenol, ice and rest if needed.

XRAY: Vertebral body heights are normal. There is intervertebral
disc space narrowing at L4-5. There is a minimal degree of perceived
retrolisthesis of L4 on L5 which remains fixed between flexion and
extension. No other significant spondylolisthesis is seen. Minimal
degree of anterior osteophyte formation seen at L3-4.

MRI FINDINGS:
Subtle dextroscoliosis of the lumbar spine is noted on the coronal
images. Slight straightening of normal lumbar lordosis is noted
suggestive of muscle spasm. Slight decreased disc height and hydration
is noted at the L3-4 and L4-5 levels. There is no focal marrow
replacement or marrow edema of the lumbar vertebrae. The conus
medullaris appears within normal limits terminating at the L1 level.
The presence of 5 lumbar vertebrae is presumed.

T12-L1: There is no central canal or foraminal stenosis. No
significant posterior disc protrusion is evident.

L1-2: There is no central canal or foraminal stenosis. No significant
posterior disc protrusion is evident.

L2-3: There is no central canal or foraminal stenosis. No significant
posterior disc protrusion is evident.

L3-4: There is a diffuse disc bulge of the annulus fibrosus measuring
approximately 2 mm AP dimension which encroaches upon the anterior
surface of the thecal sac. Central annular tear is again noted.
Together with facet joint degenerate changes, ligamentum flavum
hypertrophy and posterior epidural lipomatosis a minimal degree of
central canal stenosis is noted. No significant foraminal stenosis is
evident. Essentially stable appearance is noted at this level when
compared to prior study.

L4-5: Since previous examination there has been right hemilaminotomy
with discectomy. Previously noted right paracentral disc herniation of
the protrusion type is no longer evident. There is no central canal
stenosis. No significant enhancing soft tissue/epidural fibrosis/scar
is evident. A mild degree of right foraminal stenosis is noted due to
right posterior lateral bulging and facet joint degenerative changes
with encroachment upon the exiting right L4 nerve root. Progression in
this area is noted when compared to prior study. This is best
visualized on sagittal T2 weighted image 12.

L5-S1: There is a diffuse disc bulge of the annulus fibrosus measuring
less than 2 mm in AP dimension which encroaches upon the anterior
surface of the thecal sac. No significant foraminal stenosis is
evident. Minimal facet joint degenerate changes are evident. There is
essentially stable appearance at this level when compared to prior
study.

CONCLUSION:

1. Slight straightening of normal lumbar lordosis is noted consistent
with muscle spasm. Subtle dextroscoliosis of the lumbar spine is
noted.

2. There is essentially stable appearance of intervertebral disc
pathology at the L3-4 and L5-S1 levels as detailed above.

3. Since previous examination postsurgical changes are noted at the
L4-5 level as detailed above. No recurrent central disc protrusion is
evident. Right foraminal stenosis is noted at this level as detailed
above which appears to represent progression since previous
examination.

[Donald Corenman, MD, DC]

#34235

Your MRI notes; L3-4: “Together with facet joint degenerate changes, ligamentum flavum hypertrophy and posterior epidural lipomatosis a minimal degree of central canal stenosis is noted. No significant foraminal stenosis is evident”.
L4-5: ‘A mild degree of right foraminal stenosis is noted due to right posterior lateral bulging and facet joint degenerative changes with encroachment upon the exiting right L4 nerve root”.
L5-S1:”No significant foraminal stenosis is evident”

Your symptoms on the left sound more like an L3 or L4 nerve root (This in in buttocks, but also down front of hip), as pain in the thigh and to the knee.irritation would be generated by the L3-4 or L4-5 level, either from foraminal or lateral recess compression. See https:
//neckandback.com/conditions/foraminal-collapse-lumbar-spine/ and
https://neckandback.com/conditions/lateral-recess-stenosis/

One of the key questions is whether the symptoms are aggravated by standing and relieved by sitting or lying down.

If so, you then can consider a selective nerve root block and a pain diary to see if this root is causing the symptoms. See:
https://neckandback.com/treatments/epidural-injections-and-selective-nerve-root-blocks-diagnostic-and-therapeutic/
https://neckandback.com/treatments/diagnostic-vs-therapeutic-injections/ and
https://neckandback.com/treatments/pain-diary-instructions-for-spinal-injections/

Dr. Corenman

PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
 
Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.

[BCalvert]

#34239

Wow. Thank you for the quick reply. I have been trying to narrow down what makes it feel better. Specifically the left side when active pain. Thinking back and thru yesterday and today, I would say laying down releives the left side pain. Sitting does somewhat but not as much as lying down. I have several things going on there so maybe they overlap?

[Donald Corenman, MD, DC]

#34241

If your pain in your leg develops from activity (standing or being upright), then the noted hyperlinks I gave you would fit with those symptoms.

Dr. Corenman

PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
 
Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.

[BCalvert]

#34242

Thank you

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